Socioeconomic Disadvantage and Youth Mental Health During the COVID-19 Pandemic Lockdown

Key Points Question Did the COVID-19 lockdown disproportionately affect mental health symptoms among youths in lower income households? Findings In this cohort study of 10 399 youths, the COVID-19 lockdown was associated with worsening mental health symptoms among youths in higher-income households. Meaning These results suggest that socioeconomic status may matter when considering the youth mental health outcomes of the COVID-19 lockdown, which may be important for targeted treatment approaches.


Introduction
To stop the spread of the COVID-19 virus, a months-long, countrywide lockdown limiting social interactions was set in place.Although presumed beneficial, for youths, the COVID-19 pandemic and its associated lockdown has had profound effects, including negative effects on mental health. 1 The combination of infection threat and social isolation increased fear, helplessness, insomnia, and boredom, while isolation heightened risk for depression, anxiety, and posttraumatic stress 2 ; these emotional and behavioral problems were partially influenced by family factors and parental distress. 3,4This presumed increase in emotional and behavioral problems for adolescents is particularly concerning.Adolescence is a developmental time of risk for the emergence of mental health problems, which are exacerbated among youths from low socioeconomic status households. 5fortunately, the pandemic negatively (and disproportionately) affected individuals from lower income families. 6As such, disruption to daily activities may have exacerbated mental health symptoms disproportionately among those who live in low socioeconomic status households.
However, to our knowledge, no studies have elucidated how the COVID-19 lockdown period may have exacerbated mental health across varying socioeconomic backgrounds among youths studied at multiple time points.Thus, we aimed to better understand whether any pandemic-exacerbated mental health symptoms were more pronounced for those from lower socioeconomic status households using data from the Adolescent Brain Cognitive Development (ABCD) Study (data release 4.0), a 21-site, 10-year longitudinal cohort study of brain and cognitive development in approximately 12 000 demographically and geographically diverse youths.Enrollment for the baseline visit (ages 9 to 10 years) occurred between 2016 to 2018, whereas the 2-year follow-up (ages 11 to 12 years) halted data collection for some youths due to the COVID-19 lockdown.As some youths underwent the 2-year follow-up visit prior to the lockdown, this dataset provides the context of a natural experiment-like design to evaluate how development may have been associated with the pandemic.We hypothesized that the pandemic would be associated with worsening mental health, particularly for internalizing behaviors, such as anxiety and depression, and that these associations would be exacerbated in youths from lower socioeconomic status households.

Methods
The ABCD Study design, recruitment, and protocols are published in numerous articles. 7A centralized institutional review board research approval was obtained from the University of California San Diego; written consent was obtained from caregivers, and verbal assent was provided by the youths.The current report follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.We included measures obtained from the demographic questionnaires (including an income-to-needs ratio [INR]), Child Behavior Checklist (CBCL), 8 and Family Environment Scale (FES) from the 1-year follow-up (aged 10 to 11 years) and 2-year follow-up (aged 11 to 12 years) appointments.This design allowed us to examine changes in mental health problems prior to and after the onset of the COVID-19 lockdown.Only youths who were missing data from the 2-year follow-up visits that were of interest to our study were excluded.This resulted in a final sample of 10 399 youths.
Siblings were initially included in the analyses to be as inclusive as possible, and sensitivity tests were conducted to determine whether their inclusion was associated with different outcomes.

Demographics
Caregivers reported on the youth's sex at birth, date of birth (from which years in months was calculated), race and ethnicity, along with their education, annual household income, and number of people residing in the household.Twenty-nine options existed for caregivers to self-select their child's race, which were collapsed into 6 categories (eg, American Indian or Alaska Native/Native Hawaiian or Pacific Islander, Asian, Black, multiracial, White, other [free answer question]) for descriptive purposes only.Two options were available for caregivers to self-select for their child's ethnicity: (1) Latinx or Hispanic or (2) not Latinx or Hispanic.Caregiver highest education level (22 categories) was obtained for both the attending caregiver at the visit, as well as any other caregivers, and for analysis purposes, was collapsed into 5 categories (ie, below high school diploma, high school diploma/general education diploma, some college, bachelor's degree, postgraduate degree).Total family income was collected using a 10-category scale representing various income ranges (eg, below $5000 to more than $200 000).An INR was calculated by dividing the total household income (ie, the mean income range of each category) at baseline (youths aged 9 to 10 years) by the poverty rate per household size, according to the 2017 federal poverty guidelines 9 ; lower values indicate lower socioeconomic status.Baseline household income was used because this is fairly stable.

Child Behavior Checklist
Caregivers completed the CBCL, 8 which was designed to assess emotional and behavioral symptoms in youths aged 6 to 18 years.Item-level responses to this 113-item questionnaire consisted of 0 (not true), 1 (somewhat/sometimes true), or 2 (very true).Summary scores are available for 8 metrics: (1)   anxious/depressed, (2) withdrawn/depressed, (3) somatic complaints, (4) social problems, (5)   thought problems, (6) attention problems, (7) rule-breaking behavior, and (8) aggressive behavior.These scales form 2 overarching factors: (1) internalizing problems and (2) externalizing problems; while a total problems summary score is the summation across all 8 metrics.The internalizing factor consisted of a summed score of the anxious/depressed, withdrawn/depressed, and somatic complaints subscales.The externalizing score was a summed score of the rule-breaking and aggressive behavior subscales.

Family Environment Scale
The FES 10 is a validated assessment that was completed by the caregiver and youth.We focused on the 9-item conflict subscale, which assesses conflict among family members as reported by youth only.A summary score consists of the sum across each of the 9 questionnaire items.

Classification of Prepandemic and Intrapandemic Groups
The prepandemic group was defined as having a 2-year follow-up visit before the COVID-19 lockdown (prior to March 11, 2020).The intrapandemic group was defined as having a 2-year follow-up visit after March 11, 2020 (ie, after lockdown restrictions were implemented, and data were either collected remotely or in person once lockdown restrictions were lifted).Although 10 399 youths had available data at the 2-year follow-up, 228 of these youths had missing data at the previous visit (ie, at the 1-year follow-up).This yielded a final sample of 10 171 youths with 1-year-follow-up data available (prepandemic n = 7343; intrapandemic n = 2828) and 10 399 youths with 2-year follow-up data available (prepandemic n = 7493; intrapandemic n = 2906); missing data are reported in eTable 1 in Supplement 1.

Statistical Analysis
At the 1-year follow-up, demographic characteristics were compared between prepandemic and intrapandemic groups using χ 2 tests for categorical variables and t tests for continuous variables.To To control for familywise error rates when performing multiple comparison tests, we used the Benjamini-Hochberg method; only results that passed multiple comparisons tests were reported.
Statistical significance was determined a priori at 2-sided P < .05.All analyses were conducted in Stata version 17 (StataCorp).Given previous studies have suggested that the COVID-19 lockdown may have exacerbated family conflict, our post hoc analyses aimed to explore whether our findings remained robust when considering youth reports of family conflict.Specifically, we examined whether the group × time × INR interaction effect changed when incorporating FES scores into the models.

Results
Among the final sample of 10 399 youths, 3947 (52.3%) were male; 2084 (20.3%) were Latinx/Hispanic; 1491 (14.5%) were Black, 1252 ( ), come from families with lower income (16.5% vs 12.4%), and report a higher mean FES score (8.1% vs 7.8%) compared with individuals in the prepandemic group.At 1-year follow-up, youths in the intrapandemic group exhibited slightly higher average CBCL raw scores compared with those in the prepandemic group for anxious/depressed, somatic complaints, social problems, attention problems, rule-breaking behavior, aggressive behavior, internalizing, externalizing, and total problems.However, the averages for thought problems and withdrawn/depressed were more similar between the groups.Detailed information regarding the distributions of CBCL outcomes by groups can be found in Table 2.

INR Over Time Between CBCL Total Problems Among Youths in Prepandemic vs Intrapandemic Groups
While there was no significant evidence suggesting mean differences in CBCL Total Problems between youths in the prepandemic and intrapandemic groups over time, an increase of 1 unit in INR corresponded to a reduction in the average rate of change in Total Problems, with all other covariates held constant.Subsequent analysis including group × time × INR, found that INR moderated the group × time interactions (Table 3).This implies that, on average, greater total problems over time was associated with higher INR when comparing youths in the intrapandemic group with the prepandemic group.Specifically, when comparing individuals who differed by 1 unit on INR between prepandemic and intrapandemic groups from 1-year to 2-year follow-up, their expected difference in total problems score was 0.79 (95% CI, 0.37-1.22;false discovery rate [FDR]-corrected P < .001),holding sex, age, caregiver education, and interstudy interval constant (Figure).This finding suggests that total problems tend to be lower among youths from families with lower INR who experience the pandemic compared with those in the prepandemic group who had their follow-up visit prior to the pandemic.Further post hoc analysis suggests that after accounting for youth reports of family conflict (FES) and removal of siblings, the original findings remained unchanged.

INR Over Time Between Specific CBCL Behavioral Problems Among Youths in Prepandemic vs Intrapandemic Groups
Similarly, no significant differences in mean CBCL behavioral problems for each subscale were observed between groups over time (group × time); however, while holding other variables constant, higher INR was associated with improved behavior problem scores (eg, anxious/depressed, aggressive behavior, attention problems, social problems, rule-breaking behavior, thought problems, internalizing and externalizing problems).In subsequent analyses, INR moderated the association between group × time for most of the CBCL subscales (eTables 2-9, eFigures 1-8 in Supplement 1), except for Withdrawn/Depressed and Somatic Complaints (eTables 10 and 11, eFigure 9 and 10 in Supplement 1).In particular, for every 1-unit difference in INR, the expected differences between b The other race category was presented as free answer (no specific categories to choose from).
c INR was used as a continuous variable in these analyses, but it is reported as a categorical and continuous for ease of interpretation.

Discussion
Generally, families with lower income were more likely to experience health consequences due to COVID-19, 11 which suggests that they may also be disproportionately indirectly affected by other psychosocial stressors (eg, increased mental health problems) that stemmed from the COVID-19 lockdown.Our study used a natural experimental design to examine whether mental health problems worsened for youths aged 10 to 12 years due to the COVID-19 lockdown and whether this was exacerbated by socioeconomic status (ie, INR).Contrary to our hypothesis, among youths from higher socioeconomic status households, the COVID-19 lockdown was associated with worsening emotional and behavioral symptoms, whereas youths in families with lower socioeconomic status had better outcomes.Importantly, these associations were not driven by the well-documented increases in family conflict during lockdown. 3,12In other words, our data suggest that youths from higher-vs lower-income families may have been disproportionately negatively affected by the COVID-19 lockdown in terms of their emotional and behavioral health.analyses, but we report it as a categorical and continuous for ease of interpretation.
Some data suggest that the COVID-19 lockdown had disproportionately negative correlations in families with higher income.For example, from April to June 2019 to April 2020, individuals of higher socioeconomic status reported a greater decline in life satisfaction than those with lower socioeconomic statuses. 11Moreover, Scrimin et al 13 found that relationships between parental distress and child discomfort were only present in households with higher socioeconomic statuses, such that children in families with lower incomes may have more readily adapted to the added stressors of the pandemic.Indeed, our research group previously published data demonstrating that families with more socioeconomic disadvantage may have taken more action to alleviate emotional distress related to the COVID-19 pandemic. 14Thus, congruent with the shift-and-persist model, which describes increased resilience in more distressed families, 15 our results suggest that youths in lower-income families may have demonstrated greater emotional and behavioral resilience or been less detrimentally affected by the COVID-19 lockdown.

Limitations
The strength of this study lies in its natural experiment design, where we were able to examine within-person associations between mental health changes before and after the COVID-19 lockdown.
However, this study has limitations.The second phase of recruitment for the ABCD Study contained more youths from lower socioeconomic backgrounds and groups who have historically not been included and/or participated in research.As such, the demographics of the intrapandemic group reflect this.Relatedly, the COVID-19 pandemic and lockdown restrictions differentially affected groups from various socioeconomic and specific cultural groups, which could lead to bias in representation of our results.Notably, this study cannot provide insight into causal pathways.
examine the association between the COVID-19 pandemic lockdown and within-individual changes in CBCL outcomes from the 1-year (aged 10 to 11 years) to 2-year follow-up (aged 11 to 12 years), we conducted longitudinal linear mixed-effect models with a group (ie, prepandemic vs JAMA Network Open | Psychiatry Socioeconomic Status and Youth Mental Health During the COVID-19 Lockdown intrapandemic) × time (ie, 1-year vs 2-year) interaction term, and fixed effects for sex, age (months), INR, caregiver highest education level, interstudy interval (ie, time interval [months] between 1-year and 2-year follow-ups), as well as by participant and by study site random intercepts.Additionally, we assessed whether the association between the pandemic and the CBCL outcomes varied over time depending on INR by introducing a group × time × INR interaction term: CBCL ~Group × Time + Group × Time × INR + Sex + Age (months) + Caregiver Highest Education + Interstudy Interval + (1|site) + (1 + paritcipant ID).

Figure .
Figure.Association of INR and Total Problems Raw Score by Group Socioeconomic Status and Youth Mental Health During the COVID-19 Lockdown

Table 1 .
Participants Characteristics by Prepandemic and Intrapandemic Groups

Table 2 .
Distribution of Child Behavioral Checklist Outcomes Over Time by Prepandemic and Intrapandemic Groups a

Table 3 .
Estimated Regression Coefficient From Mixed-Effects Regression Analysis of Child Behavioral Checklist Total Problems Raw Score Between Prepandemic and Intrapandemic Groups Modified by INR, Adjusting for Interstudy Interval, Education, Age, and Sex a b INR was used as a continuous variable in our

Role of the Funder/Sponsor:
The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.The ABCD Study consortium investigators designed and implemented the study and/or provided data but did not necessarily participate in analysis or writing of this report.The ABCD Study data repository grows and changes over time.This manuscript reflects the views of the authors and may not reflect the opinions or views of the NIH or other ABCD Study consortium investigators.More information about ABCD study can be found at https://abcdstudy.org.A full list of supporters is available at https://abcdstudy.org/federal-partners/.A listing of participating sites and a complete listing of the study investigators can be found at https://abcdstudy.org/principal-investigators/.TheABCD Study data used in this report came from https://doi.org/10.15154/1503209.Frequency and Percentage of Missing Data at 1-Year and 2-Year Follow-Ups eTable 2. Results From the Regression Analysis of the CBCL Anxious/Depressed Subscale eTable 3. Results From the Regression Analysis of the CBCL Aggressive Behavior Subscale eTable 4. Results From the Regression Analysis of the CBCL Attention Problems Subscale eTable 5. Results From the Regression Analysis of the CBCL Social Problems Subscale eTable 6. Results From the Regression Analysis of the CBCL Rule-Breaking Behavior Subscale eTable 7. Results From the Regression Analysis of the CBCL Thought Problems Subscale eTable 8. Results From the Regression Analysis of the CBCL Internalizing Problems Subscale eTable 9. Results From the Regression Analysis of the CBCL Externalizing Problems Subscale eTable 10. Results From the Regression Analysis of the CBCL Withdrawn/Depressed Subscale eTable 11. Results From the Regression Analysis of the CBCL Somatic Complaints Subscale eFigure 1. Associations of the Anxious/Depressed Subscale and INR Over Time by Group eFigure 2. Associations of the Aggressive Behavior Subscale and INR Over Time by Group eFigure 3. Associations of the Attention Problems Subscale and INR Over Time by Group eFigure 4. Associations of the Social Problems Subscale and INR Over Time by Group eFigure 5. Associations of the Rule-Breaking Subscale and INR Over Time by Group eFigure 6. Associations of the Thought Problems Subscale and INR Over Time by Group eFigure 7. Associations of the Internalizing Problems Subscale and INR Over Time by Group eFigure 8. Associations of the Externalizing Problems Subscale and INR Over Time by Group eFigure 9. Associations of the Withdrawn/Depressed Subscale and INR Over Time by Group eFigure 10.Associations of the Somatic Complaints Subscale and INR Over Time by Group Disclaimer: